Noncommunicable Disease (NCD) Strategic Plans in Low- and Lower-Middle Income Sub-Saharan Africa: Framing and Policy Response
Global efforts to address NCDs focus primarily on 4-by-4 interventions – interventions to prevent and treat four groups of conditions affecting mainly older adults (some cardiovascular disease and cancers, type 2 diabetes, chronic respiratory disease) and four associated risk factors (alcohol, tobacco, poor diets, and physical inactivity).
However, the NCD burden in Sub-Saharan Africa (SSA) is composed of a more diverse set of conditions, driven by a more complex group of risks, and impacting all segments of the population.
- To document the NCD priorities identified by NCD strategic plans,
- To characterize the proposed policy response, and
- To assess the alignment between the two.
Using a two-part conceptual framework, the researchers undertook a descriptive study to characterize the framing and overall policy response of strategic plans from 24 low- and lower-middle-income countries across SSA.
The national situation assessments that ground strategic plans emphasize a diversity of conditions that range in terms of severity and frequency. These assessments also highlight a wide diversity of factors that shape this burden. Most national situation assessments include discussions of a broad range of behavioral, structural, genetic, and infectious risk factors.
Plans endorse a more narrow response to this diverse burden, with a focus on primary and secondary prevention that is generally convergent with the objectives established in global policy documents.
Broadly, the researchers observe that strategic NCDs plans developed by countries in SSA recognize the heterogeneity of the NCD burden in this region.
However, they emphasize interventions that are consistent with global strategies focused on preventing a narrower set of cardiometabolic risk factors and their associated diseases. In comparison, relatively few countries detail plans to prevent, treat, and palliate the full scope of the needs they identify.
There is a need for increased support for bottom-up planning efforts to address local priorities.
Alcohol in national strategic NCD plans across Sub-Saharan Africa
Many SSA countries reference mental health and neurological conditions, such as epilepsy, depressive and anxiety disorders, alcohol use disorders, and schizophrenia and other psychotic disorders in their narrative situation assessment to define the priorities for subsequent policy action.
Similarly, nearly all countries described the large and growing importance of the four modifiable risk factors of diet, exercise, tobacco, and alcohol in their strategic plans. All but two countries discussed the role of alcohol harm.
All countries listed at least one action aimed at reducing exposure to alcohol.
Three-quarters of SSA countries (fewer than for tobacco, diet and exercise) specified education campaigns aimed at alcohol consumption.
Two-thirds of countries described efforts to introduce or strengthen existing taxes on tobacco, alcohol, or sugary/fatty foods.
|Alcohol policy solution||Percentage of SSA countries|
|Taxes on alcohol||46%|
|Restrictions on production or marketing of alcohol||42%|
|Implement or enforce laws against driving under the influence||38%|
|Restrictions on the sale of alcohol||38%|
|Restrictions on alcohol advertising||33%|
|Implement or enforce legal age limits for alcohol consumption||21%|
|Regulate alcohol importation||13%|
|Create alcohol-free spaces||13%|
|Mandate alcohol labels||4%|
In contrast to the general objectives, for which the researchers found a general alignment between the Global NCDs Action Plan and policy interventions proposed by SSA countries, the specific interventions highlighted by the revised technical annex are less frequently reflected in strategic plans.
Still, at least those interventions targeting the modifiable risk factors, such as alcohol, are more common, with 10 of the 40 interventions found in at least half of the strategic plans (tobacco taxation, creation of smoke-free spaces, anti-tobacco media campaigns, tobacco cessation programs, alcohol taxation, prevention and treatment of alcohol use disorder, mass media campaign on health diets, public awareness campaigns for physical activity, physical education at schools, and the creation of public spaces for exercise).
Alcohol industry interference: commercial determinants of health
More than a simple coordination problem, many of the regulations face active opposition from the tobacco, alcohol, and food industries, whose economic interests are threatened. They can also stimulate opposition from within the government when they come into other government priorities, including economic and trade targets.
Global governance context of national NCD strategic plans
In response to the evolving NCDs disease burden, the World Health Assembly endorsed its first global strategy on NCDs in 2000 and released its first Global Action Plan in 2008. Since then, there have been several high-profile efforts to organize the global response to NCDs and their risk factors. After being left off of the Millennium Development Goals, both the Sustainable Development Goals (SDGs) and the Universal Health Coverage (UHC) agenda include NCDs as a priority.
Much global energy has coalesced around preventable conditions, with a focus on four major disease groups that primarily affect older adults. These include some cancers, cardiovascular disease (CVD) including ischemic heart disease and stroke, type 2 diabetes, and chronic respiratory disease (CRD). These four conditions are frequently linked to four behavioral risk factors (tobacco use, sedentary lifestyles, poor diet, and alcohol use). The so-called ‘4-by-4’ approach has recently – at the third High-Level Meeting on the prevention and control of NCDs – been expanded to include mental health and air pollution (‘5-by-5’). It seeks to reduce NCD-linked morbidity and mortality by concentrating on primary and secondary prevention, including behavior change to avoid illness and facilitate early detection and treatment to avoid the most significant morbidity.
While momentum to address NCDs was initially slow to build in low- and lower-middle-income countries (LLMICs), there has been significant progress since the WHO’s first Global Action Plan called upon countries to establish national policies targeting these conditions in 2008. WHO’s NCD monitoring reports show that the percentage of countries in the African region with an ‘Operational, integrated policy, strategy or action plan’ increased from 17% in 2010 to 37% in 2013 and 72% in 2015.
Significance of the study
Noncommunicable diseases (NCDs) have long posed significant challenges to health systems across Sub-Saharan Africa. The visibility of NCDs has risen in the wake of the epidemiological transition in the region, which is characterized by significant progress in addressing communicable disease and maternal and child health. This process is exacerbated by the demographic and social changes, as well as increasing exposure to behavioral risks, such as alcohol.
National NCD strategic plans provide a framework to coordinate multisectoral action and, as such, play a critical role in achieving UHC in Africa. They are both a vehicle to adapt these global priorities to local needs and a window into how countries articulate and frame national policy agendas.
To date, however, there has been no systematic assessment of the existing domestic NCD policy landscape.